The 7th EAHSC Building District Health Managers’ Capacity to Utilize Data for Decision-Making: A Case Study from Zanzibar Presenter: Rachel Hofmann, MSPH Co-Authors: Omar Abdalla, Jalia Tibaijuka, Samira Said, Salum Mbaruok D-tree International www.d-tree.org

The Challenge Maternal Mortality: 310/100,000 live births Neonatal Mortality 23/1,000 live births Nearly half of deliveries performed at home without a skilled attendant 99% of pregnant women in Zanzibar attend at least one antenatal care (ANC) visit, but only 53% receive at least four ANC visits Only 64% of women in Zanzibar delivering in health facilities Only 38% receiving postnatal checkups within the first two days after birth

Safer Deliveries Program 88% Referrals completed 45% of population lives in urban areas (2012 census) Facility delivery 64% DHS 2015 PNC- 35% within 48 hours DHS 2015

Safer Deliveries Program Model Ministry of Health Coordination and Oversight CHV Recruitment Training Champion Model P4P mechanism CHVs conduct household visits with clients; 3 times during pregnany and 3 times during immediate postpartum period

SO WHAT? Data Dashboards As a byproduct of care delivery, the digital tool generates data to inform decision-making. However, Zanzibar District Health Management Teams (DHMTs) lacked the skills to interpret and act on program data, which inhibited the data from being used to its full potential to improve health.

Objective and Methods Objective: Build District Health Management Teams’ (DHMT) capacity to create and implement data-driven action plans to achieve measurable improvements in healthcare delivery. Methods: Design with the user. DHMT program dashboard co-design Orientation. DHMT orientation to data analytics and dashboard Develop action plans. Quarterly action plan development and implementation Follow up. Monitoring and support D-tree co-designed programmatic data dashboards with the end-users—the DHMTs from 10/11 districts in Zanzibar—to ensure that dashboards provided interesting and actionable data for the DHMTs. After orienting teams on data analytics and dashboard navigation, we supported DHMTs in designing quarterly action plans. DHMTs reviewed the data, selected priority areas of concern, and outlined specific actions to address the issues. D-tree followed up with each team on a quarterly basis to provide technical support, monitor progress, review results, and support design of the next quarter’s action plan.

Objective and Methods

Results Results: All 10 DHMTs have developed and implemented action plans quarterly since October 2017.

DHMTs Use Program Dashboards Example from South District Visited health facilities to find out why women were paying for ANC services Found that it was a reagent for a blood test during ANC Used data to make a case to District Council for additional funding for ANC blood reagents District Council accepted the request and is releasing an additional 3,420,000 tsh to cover cost of reagent in facilities Result: Decrease from 35% (2017) to 0.5% (2018) payments for Facility ANC visits

Discussion and Recommendations The process successfully built DHMT capacity to utilize program data to inform specific follow-up actions, which resulted in measurable improvements in healthcare delivery. Recommendations: Data collected through digital technology efforts should be relevant and actionable Digital health program implementers should pair the deployment of technologies supporting data for decision-making with capacity building plans to ensure that decision-makers have the skills needed to utilize data effectively and achieve improved outcomes. “The dashboard is a very meaningful tool…it enlightens me on how things are going in my district. I can easily identify the areas where home deliveries are higher and then follow up. Before that, I guessed the reason for home deliveries, but now you get the real reasons from clients themselves…Thanks for all those who made this happen!” - Safia Khamis Juma, Reproductive and Child Health Coordinator, South DHMT

Way Forward

National CHV Program Approach Zanzibar Community Health Strategy Single cadre of community health volunteers delivering integrated service package Incorporates best practices Supported by digital platform Integrated part of national health system System wide accountability and capacity Data Driven System Zanzibar Community Health Strategy Incorporates best practices- taking the best practices from existing programs, which includes continuing with group counselling and using existing, government approved physical job aids, in addition to technology supported individual counselling/outreach  System wide accountability—link from community level to formal health system; health system capacity to oversee program, guided and managed by the Ministries of Health and Local Government Data driven system—within system, predictive analytics and machine learning to tailor visit to health and needs of each family—save resources, while maximizing health impact. External to digital system- gov‘t making decisions based on data and actual situation at community level. Using household-level data also gives us the unique opportunity to learn about patients/families who do NOT make it into the facility, without resource-intensive surveys. This helps us target the most vulnerable populations.

Community Health Information System Goal: Community data collected by CHVs can be integrated into the HMIS Unit’s Community Health Information System (CHIS) in DHIS2 Approach: CHV digital platform is interoperable with DHIS2 MOH and PORALGSD to decide on key indicators for CHIS; these will be built into CHVs’ digital tools and dashboards and captured routinely through the CHVs work Build capacity of MOH, PORALGSD, and Shehia leaders to analyze community data and utilize findings to improve community health programming Build capacity of HMIS, ICT and HPU units to manage and update the national CHV digital platform MOH will have aggregated community data available through DHIS2, as they currently have from health facilities

Acknowledgements Omar Abdalla, D-tree International Jalia Tibaijuka, D-tree International Samira Said, D-tree International Salum Mbaruok, D-tree International